Laserfiche WebLink
League of Minnesota Cities Insurance Trust <br /> Workers' Compensation and Employers' Liability Agreement <br /> Administrator <br /> Employee Benefit Administration Co. <br /> 8441 Wayzata Blvd., Suite 200 Minneapolis, MN 55426-1392 Phone (612) 544-0311 • <br /> Information Page <br /> RENEIWPI <br /> 1. The "City" Agreement No. <br /> CLIPT-1 -0F S-Ir "City" is: • City <br /> 31301 -SILVEDP! Joint Powers Entity <br /> IS Other (describe) <br /> 2. The Agreement period is from 12:01 a.m. to 12:01 a.m. at the "City's" address. <br /> 3. A. Workers' Compensation Coverage: Part One of the Agreement applies to the Workers'.Compensation Law of any state <br /> of the United States of America and the District of Columbia. <br /> B. Employers' Liability Coverage: Part Two of the Agreement applies to work in each state listed in item 3A. <br /> The limits of our liability under Part Two are: Bodily Injury-Each Claimant $200,000 <br /> Bodily Injury-Each Occurrence $600,000. <br /> Bodily Injury by Disease-Agreement Limit $600,000. <br /> C. This Agreement includes these amendments and schedules: <br /> 4. Retro-rated refund option selected? - 7 <br /> VJ. <br /> 5. The premium for this Agreement will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. <br /> All information required below is subject to verification and change by audit. <br /> Premium Basis Esti- Rates Code Entries in this item,except as specifically provided Estimated <br /> mated total annual Per 3100 of No. Elsewhere in This Agreement,Do not Modify any of the Annual <br /> Remuneration Remuneration Other Provisions of this Agreement Premium <br /> F 1 REY EN F31 UNTEE-F, <br /> =T,E::F,1I E" r NO VIDLU'A-c.-­ c <br /> C, I Ali 110 11:1 F­­ D'A F 1 0-E E S ._23 <br /> J J <br /> V .- 5 5 1 rC. C U-i,%;rS-:-!'R1_!C,T I Df!--41 L <br /> EIR I CYL "2f <br /> 4-8 <br /> FF- S­ E L!OLIOR ST <br /> C C:"-, -,&,L- <br /> Q U-D R <br /> D -c <br /> Li,_TE-W,Lj F 2 4 2, <br /> 7: <br /> M <br /> j -•Y.li I­ <br /> J <br /> E E-'r _1._E Ni i NIG 3)27 <br /> f "ERPTION <br /> SN <br /> LITY T O SHP c' ifi r.D- <br /> 71 U 5 <br /> .1 <br /> Agent: E%:p e r i e -1t'_-4: Z <br /> C-a t-,C;n <br /> F-411-4 7c:_2 <br /> Star.JEi­ Pi-e ff)i U ITI 75664. <br /> Fit-E M.IUM DiSCOUli-It 671 <br /> COF,,PORATE RESCIURCEE L <br /> C C I U 1-t e d St P-,-C-MIUM 691?5;1 <br /> 14C.11 W -;6TH ST #!-'-' C T <br /> 1 , L(C-St J. <br /> qi PL S'. r, 5,55 4 23 Net Deposlt- Fremium 606951. <br /> ERA 467(10-87) Date: <br />